Combating Depression in Medical Trainees

Following-up quickly on the previous post, because identifying a problem is fairly meaningless if you can't do anything about it. I said in that post that there are no simple answers and that's definitely true. Equally important to note is that whatever responses to this problem I present (or that anyone else presents) will likely not have much of an evidence base behind them, as there isn't much good research on this problem in particular. Reasonable theories is about all we have at this stage. In any case, if I had some all-powerful influence over medical education policies, here's what I'd try.

1) Reduce Hours

Physicians work a lot. Residents work a lot more. Medical students work less, but still quite a bit. All work more than a standard 40-hour week. Heck, a 40-hour week ever is practically luxurious. A fair bit of unofficial work is also effectively required, whether that's administrative work, reading, teaching, or research. At the extreme ends, typically residents in high-intensity fields, 100+ hours per week is commonplace (out of a total of 168 hours in a week).

While many people avoid depression despite these long hours, it's hard to see how the rate of depression and depressive symptoms goes down without some relaxation in work hours. There are many ways to treat or prevent depression, but many of them take time, time which is not available when working 100+ hours per week. Basic self-care suffers under such schedules, let alone the extra care needed to maintain or improve mental health. The correlation between resident work hours and sleep is pretty clear, for example - more hours at the hospital means less sleep overall.

Simple work hour limits have been put in place in the US to some effect, but with significant limitations. Part of the problem with straight work hour limits is that programs still need the same amount of work done by the same number of people, just with fewer hours. So, residency programs find inventive ways to get the same work done by the same number of people through creative (often undesirable) scheduling, increasing workloads during worked hours, or straight-up lying about hours worked (particularly common in surgical specialties in the US).

Another concern with reduced working hours is that it may require extension in the number of years of residency in order to maintain the number of total hours worked and allow residents to gain the necessary experience to become competent. A certain amount of exposure to a given pathology or procedure is necessary to be able to work independently, of course. The argument here is that if residency is going to be terrible, it might as well be as compact as possible to allow physicians to move onto independent practice.

All things considered, I don't believe reducing work hours alone will be particularly effective in reducing depression among residents, but I do believe it is a necessary component to any solution. I believe it needs to come in conjunction with efforts to make residency training more effective in terms of educational outcomes, and more efficient in terms of workload completion. I see substantial room for improvement on both these fronts.

2) Orientation and Role Definition

One thing that's always struck me about medicine is how little orientation people get to their surroundings. Physicians-in-training are thrown into situations without any idea as to what their responsibilities are or how to carry out those responsibilities. I had a better orientation when I worked at McDonald's in high school than I have at any point during my medical training.

The disjointed nature of medical training does not help this process. During my clerkship, I had one rotation that lasted 6 weeks, one rotation that lasted 4 weeks, and one rotation that lasted 3 weeks. Everything else lasted for 2 weeks or less. By the end of a 2 week rotation, I would usually have a decent idea as to what I was supposed to be doing and how to start doing it somewhat effectively, but by that point, it was onto the next rotation and the whole process started over again.

Having a clear role, and having that role understood by those around you (especially superiors) is an important factor in overall job satisfaction. I see little reason to think this doesn't apply equally to physicians-in-training.

Ideally this would be accomplished with dedicated time for orientation combined with a degree of standardization of roles for learners between all rotations, but that may be overly ambitious. An easier change to implement could be simply having instructions for trainees put down in writing and communicated to both learners and instructors. This would not take much effort to accomplish, yet I found this simple document was not present for most of my rotations.

3) Allow Greater Flexibility in Education

Working hard, long hours sucks. Working hard, long hours you have some say over sucks a whole lot less. People who have control over their schedules tend to have much higher satisfaction with their work and their lives.

Realistically, students and residents are never going to have complete autonomy over their schedules. Yet, they could have a lot more control than they currently have. When talking about long hours, while many would prefer intensive, shorter residencies, some may want longer residencies with more favourable hours - yet this is an option only at a small handful of residency programs (usually Family Medicine programs).

Likewise, there are a lot of aspects to medical training which are mandatory across-the-board without having across-the-board value. My school has 12 weeks of required surgical training, yet the majority of students will never step foot in an OR after finishing residency. Likewise, of those who are going to be in the OR, do they need the full 6 weeks of training in both Family Medicine and another 6 weeks in Psychiatry? Would half the training in each make that much of a difference in overall competence once training is completed? Could that time be better spent if freed up for more electives or selectives? Some training in surgery, psychiatry, and family medicine seems necessary for all physicians, but additional exposure comes with diminishing returns.

Similarly, having some control over productivity within the day-to-day schedule may be beneficial. Pretty much every residency program has academic half-days and function well enough with residents missing for a period of time to attend mandatory lectures. Would it be possible to give residents a half-day to set their own schedules, whether that's working on research, attending specific clinics, or gaining more experience with useful procedures.

4) Just Treat Each Other Better!

Physicians aren't terribly nice to each other. I believe we're largely past the times where physicians used to be outright cruel to each other, but kindness is still often lacking. Encouraging words come far less frequently than they could or should. Gratitude between physicians is less frequent and less genuine than it could be ("Thank you for sending us this consult" isn't really a statement of appreciation as much as a nicety). When someone is sick, or needs to go pick up their kid from daycare, or just struggling to keep up, would it be that terrible to send them home when there's enough people around to do the work at hand - even if it means a little extra effort on the part of those left? All my other jobs managed these situations well enough, including those in health care.

5) Wellness Programs

In general, I'm not a fan of wellness programs currently being rolled out at many medical education institutions. They feel like trying to put a small bandage on a wound after waving around a knife that inflicted the wound in the first place. It's better than nothing, but not nearly adequate and doesn't address why a bandage was necessary in the first place. I find them to be inconvenient for most people and maintains the onus on trainees to help themselves. They often provide resources that are already available in the community in one form or another. As a result, they are often most utilized by those already motivated to improve their situations and willing to make sacrifices to do so - individuals who might have been able to pull themselves up even without a dedicated wellness program.

Still, some of the typical elements of wellness programs have some good evidence behind them. Meditation, yoga, and tai chi do have some benefits to mental health - as does exercise and mindfulness in general. Opportunities to talk through problems, or to reflect on them individually, can both be beneficial. Being able to reframe problems as opportunities, to develop a problem-solving attitude, can be quite useful in forming resilience to challenges. While I dislike the emphasis on wellness programs, they can be part of the solution for a subset of trainees.

To wrap things up, we're never going to eliminate depression or other forms of mental health problems from medicine. There will always be some medical students, residents, and staff struggling with low mood. However, it's clear that the rates of depression are higher than baseline, well higher than they could be given the resources the profession has at its disposal, and certainly higher than is ideal for high-quality patient care. There's a lot we could be doing to minimize this problem.

Investment vs Consumption in Healthcare

It's no secret that healthcare budgets these days are under stress. As provincial governments look with concern to current healthcare costs, as well as to potential future healthcare costs with our graying demographics, there's plenty of incentive to minimize spending within the medical community.

While I disagree with some of the approaches being taken, it's a worthy goal - not everything in healthcare is cost-effective, and there's good reason to think that freeing up money for other social expenses could be more be more beneficial than many direct medical expenditures. It's also an opportunity to dig into the role of medicine in our society and what we actually expect for the rather large sums of money we throw at our healthcare system.

Healthcare comprises both elements of investment (expenses which are expected to yield an economic return) and consumption (expenses which are not expected to yield an economic return but which hopefully confer benefits to longevity or quality of life). That's a bit too sharp of a split - in reality, all healthcare should be improving the quantity and quality of life of patients and most expenses tend to have some sort of an economic return, even if that return falls below the medical expense and wouldn't be worthwhile as an investment alone.

However, the degree to which we priority each element - investment vs consumption - tells us a fair bit about how we view healthcare's role. These priorities in turn can dictate how much we spend on healthcare overall.

Right now, in Canada and much of the rest of the western world, the focus is on consumption. When people rally for better access to medical services, it's usually for the immediate impact on patients' quality of life. Likewise, when analyzing an intervention's merit, we tend to focus on cost-effectiveness, using metrics like cost per Quality-Adjusted Life Year (QALY). These capture quality of life gains, and analyze all medical interventions as though they were consumptive in nature, but generally ignore economic returns on expenditures.

It's difficult to view and analyze healthcare from an investment perspective, however. For one, it's really hard to accurately measure return on investment when it comes to medical interventions - QALYs or similar metrics are much easier to determine. Second, doing so requires making judgments on the economic worth of individual people (or groups). Most of us are pretty uncomfortable thinking of human lives in economic terms. Physicians especially try to avoid these judgments, as they can devalue certain groups, especially the vulnerable and those in need of the most help.

Yet, there are some broader programs that make no direct judgment on individual worth, yet would have clear beneficial investment components in addition to their meaningful improvements on quantity and quality of life. Mental health is a major one. It hits adolescents and younger adults frequently and is a significant impairment when it comes to productivity at work or school. Individuals who are not currently working are also at high risk for mental health problems, particularly the elderly with dementia and/or depression, of course, but compared to many other medical services we provide, the benefits from investments in mental health more frequently affect individuals who could be more economically productive if optimally treated. When we start making the hard choices about which programs and services are worth funding, it may be worth putting a higher emphasis on economic returns - it might make our tax dollars go a little bit further and lessen the burden of our healthcare expenditures.

I'm rambling a bit, so I'll wrap up by saying this: we want to be healthy and our medical system is a major part of that. However, healthcare does more than just improve health and other social services play a big role in improving health overall. It's worth taking a step back every once in a while to reevaluate our priorities in medicine, to be critical about what how best we can serve the societies we live in, and how some parts of our healthcare system - even the helpful parts - might not be worth the cost when compared to alternatives.

Mental Health and Resources - Addendum

Since my last post, I've had a few opportunities to chat about the state of mental healthcare in the area, particularly what could be done to improve the situation. It's in the news a fair bit now, so it's come up in conversation a lot, particularly while on my Psych rotation. One idea that came up was increasing Psychiatrist work hours.

It's a valid thought. Psychiatrists do work fewer hours than most other physicians, especially hospital-based physicians. If any physician can be told that they need to work longer hours, it may be Psychiatrists. However, I'd like to push back against that notion for a few reasons.

First, while Psychiatrists work fewer hours than many other physicians, is that because Psychiatrists are working too few hours, or because other physicians are working too many? I'd argue it's the latter. Psychiatrist hours still average over 45 a week, not much below that of other specialties, particularly office-based practices. Given overall rates of physician burnout and unhappiness with work-life balance, asking Psychiatrists to work longer hours would likely help one problem by causing another.

Second, while no physician works optimally when tired, tired Psychiatrists can be particularly troublesome. Psychiatrists have to be careful not just with their clinical decisions, but their words as well. Emotional lability increases with exhaustion or chronic mental fatigue - a bad thing for all physicians, but particularly for one who has to stay mindful of their phrasing whenever they interact with a patient. With non-psychiatric patients, words matter of course, but the margin for error is much greater - a poorly phrased statement can typically be apologized for, clarified, or otherwise explained without enduring consequences. Not so with some psychiatric patients.

Lastly, there's only so much additional hours from Psychiatrists will do to help. It wouldn't help with inpatient services. It wouldn't help with community supports. It wouldn't help with long-term care availability. At best, it would help reduce outpatient wait times. That's still a desirable outcome, though I doubt that longer hours for Psychiatrists would be anywhere near enough. If wait times could be reduced from 1 year to, say, 9 months, that would be a positive change, but 9 months is still far too much time. 

It's a tough situation. As our society increasingly accepts mental health as an important priority, demand for mental health services will also increase. Realistically, all options should be on the table, including longer working hours for Psychiatrists. However, we need to avoid band-aid solutions and "work harder" is pretty close to my definition of a band-aid solution. Other approaches are necessary and, I believe, should be explored first before simply asking current workers to do more.

Mental Health and Resources

I'm on my Psych block now. I'll give my final thoughts on the rotation when I'm further into it, but for now, I'd like to take a minute to express my deep frustration with the availability of medical services in this country and my area in particular. Long story short, we need more beds, more services, and more resources in general.

I have plenty of frustrations about the medical system in general. That's kind of the point of this blog, to get those frustrations out constructively. A lot of my concerns relate to the actions of physicians as a group, as well as physician-dominated organizations including medical schools. I think we, as a profession, hold a lot more blame for the problems in medicine than we're generally willing to admit, and that we have a lot more power to push forth positive change than we currently exercise. I try to advocate for internal changes within the profession of medicine ahead of or in conjunction with changes outside of the medical profession. I especially try to avoid lobbying for more money to be thrown at any particular problem, because resources are finite and while money can paper over a lot of structural problems, they don't solve them either. Those structural issues need to be tackled regardless and doing so may remove the need for more funding.

Not so much when it comes to mental health. The state of mental healthcare in my region is receiving a lot of scrutiny, justifiably, due to a number of frankly horrible situations that have occurred recently or not-so-recently. A lot of these criticisms have been directed towards the government, particularly the provincial government, and I largely agree with those criticisms. Some of the criticism has been directed towards the hospital I'm training at, the physicians and other healthcare workers involved in care for those with mental health, as well as the school I attend. For once, I can't agree with these criticisms. The hospital has clearly tried to prioritize mental health. Employees and physicians have largely just tried to make the best of a bad situation, accepting what is objectively a poor situation because no better alternatives exist. Even the school has gone out of their way to increase the number of Psych residents to help with the workload and encourage more Psychiatrists to stay in the area.

When valuable 1-on-1 therapy is virtually impossible to achieve without insurance or significant independent funding, when long-term care facilities are routinely unavailable, when the mental health ward is operating above 100% capacity (even after accounting for those waiting for long-term care), when wait lists to see an outpatient psychiatrist are on the order of months or years... even monumental changes in the organization of services aren't going to cut it.

Psychiatry does have its share of problems that can be laid at the feet of physicians, of that I have no doubt. However, it's pretty clear that more resources are needed. I don't see mental health being substantially improved without more inpatient beds as well as more supports both in and out of the hospital.